Health Assesment Exam 1

Which critical thinking skill helps the nurse see relationships among the data?

clustering related clues

What are the steps of the nursing process?

Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

Diagnostic reasoning helps form the?

Diagnostic hypothesis

What are the four types of database a nurse can collect?

1. complete total health database

2. episodic/problem centered database

3. follow-up database

4. emergency database

A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?

a. Collect history information first, then perform the physical examination and institute life-saving measures.

b. Simultaneously ask history questions while performing the examination and initiating life-saving measures.

c. Collect all information on the history form, including social support patterns, strengths, and coping patterns.

d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.

B

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?

a. Establish priorities.

b. Identify expected outcomes.

c. Evaluate the individual's condition, and compare actual outcomes with expected outcomes.

d. Interpret data, and then identify clusters of cues and make inferences.

D

Match the following to what nursing stage they describe:

a. Has little experience with a specified population and uses rules to guide performance.

b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution.

c. Sees actions in the context of daily plans for patients.

d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.

A. Novice

B. Expert

C. Competent

D. Proficient

Should you use "friendly small talk" in the introduction stage of an interview?

No

During an interview, the nurse states, "You mentioned having shortness of breath. Tell me more about that." Which verbal skill is used with this statement?

a. Reflection

b. Facilitation

c. Direct question

d. Open-ended question

D

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?

a. "Mr. Y., at your age, surely you have been hospitalized before!"

b. "Mr. Y., I just need permission to get your medical records from County Medical."

c. "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?"

d. "Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?"

D

What are the verbal responses that focus on the healthcare provider's perspective?

CIES

Confrontation, interpretation, explanation, and summary

What are the verbal responses that focus on the patient's perspective?

FRECS

Facilitation, reflection, empathy, clarification, silence

As the nurse enters a patient's room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, "I'm so afraid of, um, you know." What is the most therapeutic response, and what verbal response is it categorized as?

a. "You're afraid you might lose your breast?"

b. "No, I'm not sure what you are talking about."

c. "I'll wait here until you get yourself under control, and then we can talk."

d. "I can see that you are very upset. Perhaps we should discuss this later."

A

Rationale: Reflection echoes the patient's words, repeating part of what the person has just said. Reflection can also help express the feelings behind a person's words.

A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:

a. Talking too much.

b. Using confrontation.

c. Using biased or leading questions.

d. Using blunt language to deal with distasteful topics.

C

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this?

a. An aged person has a longer story to tell.

b. An aged person is usually lonely and likes to have someone with whom to talk.

c. Aged persons lose much of their mental abilities and require longer time to complete an interview.

d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said.

A

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?

a. Determine the communication method he prefers.

b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading.

c. Request a sign language interpreter before meeting with him to help facilitate the communication.

d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.

A

A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation?

a. The woman is nervous and embarrassed.

b. She has something to hide and is ashamed.

c. The woman is showing inconsistent verbal and nonverbal behaviors.

d. She is showing that she is carefully listening to what the nurse is saying.

D

Rationale: Eye contact is perhaps among the most culturally variable nonverbal behaviors. Asian, American Indian, Indochinese, Arabian, and Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their eyes during the interview. American Indians often stare at the floor during the interview, which is a culturally appropriate behavior, indicating that the listener is paying close attention to the speaker.

A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next?

a. The nurse should try to relax; these behaviors are culturally appropriate for this person.

b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview.

c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors.

d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.

A

The nurse makes this comment to a patient, "I know it may be hard, but you should do what the doctor ordered because she is the expert in this field." Which statement is correct about the nurse's comment?

a. This comment is inappropriate because it shows the nurse's bias.

b. This comment is appropriate because members of the health care team are experts in their area of patient care.

c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation.

d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

C

During an interview, the nurse would expect that most of the interview will take place at what distance?

a. Intimate zone

b. Personal distance

c. Social distance

d. Public distance

C

Rationale: Social distance, 4 to 12 feet, is usually the distance category for most of the interview. Public distance, over 12 feet, is too much distance; the intimate zone is inappropriate, and the personal distance will be used for the physical assessment.

How would we document the reason for seeking care?

As the brief, spontaneous statement as said by the pt in ""- if multiple answers, focus on most important

What is the purpose of a health history?

To provide a database of subjective information about the patient's past and current health

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?

Patient denies . . .

What is the purpose of the review of systems?

(1) evaluate the past and current health state of each body system

(2) double check facts in case any significant data were omitted in the present illness section

(3) evaluate health promotion practices.

Which best describes a genogram?

A graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members

As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make?

a. No further MMR immunizations are needed.

b. MMR vaccination needs to be repeated at 4 to 6 years of age.

c. MMR immunization needs to be repeated every 4 years until age 21 years.

d. A recommendation cannot be made until the physician is consulted.

B

When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?

a. Family history

b. Review of systems

c. Functional assessment

d. Reason for seeking care

C

Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care.

A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be:

a. "Can you tell me what they look like?"

b. "Don't worry about it. You are only taking two medications."

c. "How long have you been taking each of the pills?"

d. "Would you have a family member bring in your medications?"

D

The other answers would not help to identify the medications

What is the CAGE test and what does CAGE Stand for?

The CAGE test is known as the "cut down, annoyed, guilty, and eye-opener" test. If a person answers "yes" to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.

What does FICA stand for?

faith and belief, importance and influence, community, and addressing or applying in care

What OBJECTIVE DATA do you study in the general survey?

1. Physical appearance

2. mobility

3. body structure

4. behavior

5. measurements

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

a. Increase in body weight from his younger years

b. Additional deposits of fat on the thighs and lower legs

c. Presence of kyphosis and flexion in the knees and hips

d. Change in overall body proportion, including a longer trunk and shorter extremities

C

Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

The nurse should measure rectal temperatures in which of these patients?

a. School-age child

b. Older adult

c. Comatose adult

d. Patient receiving oxygen by nasal cannula

C

Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused persons, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.

When should a tympanic membrane temperature be used and not be used?

The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting.

What objective data do we collect about PHYSICAL APPEARANCE in the general survey?

ASSFOL

Age

Sex - appropriate for age?

Skin color

Facial features

Overall appearance

LOC

What factors influence body temp?

Normal temperature is influenced by the diurnal cycle, exercise, and age.

What do we record under the "body structure" portion of the general survey?

SSPPN

Stature

Structure

Postion

Posture

Nutrition

What do we look for regarding the "mobility" portion of the general survey?

Gait - foot placement, ROM, no involuntary movement

What is dwarfism?

Shortness in height that results from the under secretion of growth hormone

What are the two types of dwarfism?

hypopituitary and achondroplastic

What is gigantism?

overproduction of growth hormone before puberty

is anorexia nervosa an abnormality in body structure?

Yes

What is cushing's syndrome (endogenous obesity)?

Signs are a fatty hump between the shoulders, a rounded face, and pink or purple stretch marks, caused by exposure to high cortisol levels for a long time.

What is Marfan syndrome?

An inherited genetic disorder affecting the CT, causing heart and vision problems, tall, thin frame, and long extremities

What do we look for regarding the "behavior" portion of the general survey?

facial expressions, mood, affect, speech, dress, personal hygeine

What is the difference between mood and affect?

they are congruent, but affect is the observable manifestation of a person's mood

What data do we record on the "measurements" portion of the general survey?

1. Weight

2. height

3. BMI

4. waist-circumference ans weight-to hip ratio

What is are abmormal waist circumferences?

35 inches or more in women and 40 inches or more in men

What are the BMI ranges?

underweight:

What is the definition of nutritional status?

degree of balance between nutrition intake and requirements

What are the stages of "nutrition through the lifespan?

1. Infants and children

2. adolescence

3. adulthood

4. the aging adult

What is important to understand about nutrition for infants and children?

Age 0-4 mo is period of most rapid development, nutrition is vital for development of CNS

What is important to understand about nutrition for adolescents?

due to rapid physical growth and endocrine and hormonal changes, nutrition needs increase and snacks may be necessary

What is important to understand about nutrition for adulthood?

Nutrition needs stabilize, and lifestyle factors are very important because they influence future health (such as development of metabolic syndrome

What are the factors of metabolic syndrome?

high waist circumference, high triglycerides, low HDL, hypertension, insulin resistance, prothrombotic or proinflammatory states

What is metabolic syndrome?

A group of conditions that increase the risk of heart disease, stroke, and diabetes, atherosclerosis. Must have 3 or more of the factors

What is important to understand about nutrition for the aging adult?

increased age = increased age for over or under nutrition

normal physiologic changes affect nutritional status

energy requirements decrease

Regarding cultural competence with nutrition, what cultural factors must be considered?

1. cultural definition of food

2. amount of meals eaten away from home

3. amounts of types of food

4. forbidden foods

What is nutrition screening?

a quick, first-step method to obtain data

What are the steps of nutrition screening?

1. establish parameters

2. screen

3. use standardized dietary guidelines to determine adequacy of diet

4. determine if pt is identified as a nutritional risk

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to:

a. Immediately notify the physician.

b. Consider this finding normal in children and young adults.

c. Check the child's blood pressure, and note any variation with respiration.

d. Document that this child has bradycardia, and continue with the assessment.

B

Sinus arrhythmia is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration.

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is:

a. "The numbers are within the normal range and are nothing to worry about."

b. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart."

c. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."

d. "The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure."

C

The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question and use terms he can understand.

What are factors that influence BP (in a literal sense ie not age, stress, etc)

cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls.

A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:

a. After menopause, blood pressure readings in women are usually lower than those

taken in men.

b. The blood pressure of a Black adult is usually higher than that of a White adult of the same age.

c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight.

d. A teenager's blood pressure reading will be lower than that of an adult.

B

In the United States, a Black adult's blood pressure is usually higher than that of a White adult of the same age. The incidence of hypertension is twice as high in Blacks as it is in Whites. After menopause, blood pressure in women is higher than in men; blood pressure measurements in people who are obese are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years.

The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:

a. Yield a falsely low blood pressure.

b. Yield a falsely high blood pressure.

c. Be the same, regardless of cuff size.

d. Vary as a result of the technique of the person performing the assessment.

B

Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery.

What is an auscultatory gap?

a period when the Korotkoff sounds disappear during auscultation.

how do you avoid missing an auscultatory gap?

Take a palpatory pulse first and inflate the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappear

The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

a. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate.

b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.

c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.

d. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

C

An auscultatory gap occurs in approximately 5% of the people, most often in those with hypertension. To check for the presence of an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears.

What is pulse pressure?

Pulse pressure is the difference between systolic and diastolic blood pressure (170 - 100 = 70) and reflects the stroke volume.

The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure?

a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure.

b. The best position to measure thigh pressure is the supine position with the knee slightly bent.

c. If the blood pressure in the arm is high in an adolescent, then it should be

compared with the thigh pressure.

d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels.

C

. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

a. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise.

b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia.

c. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.

d. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly

B

The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.

What is acromegaly?

Excessive secretions of growth hormone in adulthood after normal completion of body growth causes an overgrowth of the bones in the face, head, hands, and feet but no change in height.

What might happen if a nurse fails to recognize an auscultatory gap?

a falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension.

What is mean arterial pressure?

MAP is the pressure that forces blood into the tissues, averaged over the cardiac cycle. Stroke volume is reflected by the blood pressure. MAP is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer; rather, it is a value closer to diastolic pressure plus one third of the pulse pressure.

The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have?

a. Hypopituitary dwarfism

b. Achondroplastic dwarfism

c. Marfan syndrome

d. Acromegaly

A

Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities;

the nurse is counting an infant's respirations. Which technique is correct?

a. Watching the chest rise and fall

b. Watching the abdomen for movement

c. Placing a hand across the infant's chest

d. Using a stethoscope to listen to the breath sounds

B

infant's respirations are normally more diaphragmatic than thoracic.

When checking for proper blood pressure cuff size, which guideline is correct?

a. The standard cuff size is appropriate for all sizes.

b. The length of the rubber bladder should equal 80% of the arm circumference.

c. The width of the rubber bladder should equal 80% of the arm circumference.

d. The width of the rubber bladder should equal 40% of the arm circumference.

D

The width of the rubber bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference.

While measuring a patient's blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply.

a. The person supports his or her own arm during the blood pressure reading.

b. The blood pressure cuff is too narrow for the extremity.

c. The arm is held above level of the heart.

d. The cuff is loosely wrapped around the arm.

e. The person is sitting with his or her legs crossed.

f. The nurse does not inflate the cuff high enough.

A, B, D, E

What are the 6 nutritional screening tools?

1. 24 hr recall

2. food frequency questionnaire

3. weight questions

4. food diaries

5. direct observation

6. food pattern questionnaire

What should you do if you identify a patient as a nutritional risk

Do a comprehensive nutritional assessment

What two broad things are included in the comprehensive nutritional assesment

1. Subjective data - nutritional history

2. objective data - clinical signs (observation of appearance)

what extra information should you include in a comprehensive nutritional assessment for adolescents?

their present weight, anabolic steroid use, overweight risk factors, age of first menstruation

what extra information should you include in a comprehensive nutritional assessment for pregnant women?

number of pregnancies, pregnancy history, food preferences when pregnant

what extra information should you include in a comprehensive nutritional assessment for the aging adult?

prior dietary history, factors affecting present intake, vitamin D and calcium intake

What clinical signs do we observe under the objective data part of the comprehensive nutritional assesment?

normal appearance

signs associated with malnutrition

nutrient deficiency associated with each sign

anthropomorphic measures

What are the anthropomorphic measures for the comprehensive nutritional assessment?

Derived weight measure

waist-to-hip ratio

arm span/total arm length

serial asssesment

What are the steps in diagnostic reasoning (Hypothetico-deductive model)?

1. Attend to initially available cues (pieces of information).

2. Formulate diagnostic hypotheses (tentative explanation of cues).

3. Gather relevant data.

4. Evaluate each hypothesis with ongoing data collection.

5. Serve as basis for ongoing investigation.

What does OLDCARTS stand for?

Onset, Location, Duration, Character, Associates s/s, Response to Tx, Treatment, Severity

What does HPI stand for?

history of present illness

what does PMH stand for?

past medical history

What forms the database?

Database = subjective data + objective data + patient's record + laboratory studies

How have we expanded the concept of health?

By incorporating the Holistic model assessment, Health promotion and disease prevention, and culture and genetics

What is Evidence based Practice?

Clinical decision-making based on:

1. integration of research evidence

2. clinical expertise and clinical knowledge

3. patient values and preferences

What are the ten traps of interviewing?

1. Providing false assurance or reassurance

2. Giving unwanted advice

3. Using authority

4. Using avoidance language

5. Engaging in distancing

6. Using professional jargon

7. Using leading or biased questions

8. Talking too much

9. Interrupting

10. Using "why" questions

What are the 8 nonverbal skills?

1. Congruency between your verbal and nonverbal messages

2. Physical appearance - form's initial perception

3. Posture - body language

4. Gestures

5. Facial expression - don't have an rbf

6. Eye contact - maintain within the realm of interest but

be mindful of cultural diversity.

7. Voice - beware of tone

8. Touch - a person's receptivity is influenced by a variety of factors

In the process of communication, what are the four internal factors?

- Liking others (genuine)

- empathy

- ability to listen

- self-awareness - be aware of "implicit bias"

In the process of communication, what are the 5 external factors?

- ensure privacy - goographic and psycological

- avoid interruptions

- physical environment - equal status seating

- dress

- note-taking - keep to a minimum

What are 5 characteristics of a successful interview?

- Gather data

- Establish trust

- Teach person about their health state

- Build rapport

- Discuss health promotion and disease prevention

Who are some groups in which communication might be approached differently?

older adult, special needs, those with language barriers, those with decreased health literacy, LGBTQ